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Answer: If the baby has minor problems at the visit, you should bill a sick visit based on whether the pediatrician or another member of the same tax group provided professional services to the newborn in the hospital. If your pediatrician attended to the newborn in the hospital, you should report an established patient office visit (99212-99215). If the newborn is new to the practice and no other provider from your group treated the patient, assign a new patient office visit (99201-99205). Select a diagnosis that reflects any problems that the baby might have. For example, if the baby has jaundice that requires treatment, assign 774.6 (Unspecified fetal and neonatal jaundice). For feeding problems, you should report 779.3 (Feeding problems in newborn). If the baby is losing weight, use 783.21 (Loss of weight).
If the baby is well at the visit, use a diagnosis code that reflects why the pediatrician wanted to see the baby. For instance, he may have been concerned about possible jaundice in the hospital, but when he sees the baby at 4 days of age, the jaundice has resolved. You can still report jaundice (774.6) because it explains the reason for the visit. In addition, use follow-up examination code V67.9 (Unspecified follow-up examination) to show that the jaundice resolved. Or the newborn may have lost weight in the hospital, which prompted the follow-up visit. Regardless of the infant's current weight, you can use feeding problems to reflect the pediatrician's concern. You may also report V29.x (Observation and evaluation of newborns and infants for suspected condition not found) in the secondary position to indicate that the doctor was concerned about a problem but did not find any problems during the examination.
You correctly refer to these early visits as follow-up hospital visits. Do not code them as well visits. Reporting a preventive medicine service (99391,Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; infant [age under 1 year]) will use up one of the child's allotted annual visits. In addition, noting any problems will contradict the intent of the well visit.
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